=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427591767
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIANA O'BRIEN, LCSW. MED, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2016
-----------------------------------------------------
Last Update Date | 11/18/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5675 STONE RD STE 300
-----------------------------------------------------
City | CENTREVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20120-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-930-5498
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5675 STONE RD STE 300
-----------------------------------------------------
City | CENTREVILLE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20120-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-930-5498
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | DIANA O'BRIEN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 703-930-5498
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 0904005203
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------